Would you like to have a mental illness? Let me be more precise: Do you seek a name for your suffering? An official diagnosis could enable you to receive health insurance, benefits or special services from schools; to get prescription drugs; and perhaps to conceive of yourself as someone capable of getting better.
Well, has the American Psychiatric Association (APA) got a book for you! The Diagnostic and Statistical Manual of Mental Disorders (DSM) does it all, proffering those handy little numerical codes that make its take on suffering seem authoritative and scientific.
“This is the bullshit problem,” says Gary Greenberg, author of The Book of Woe: The DSM and the Unmaking of Psychiatry. “It’s not that they’re lying, but they’re also not telling the truth. They just say that this is scientific and everything follows from there.”
A practicing psychotherapist and investigative journalist, Greenberg has made a career of applying the reporter’s slicing skepticism to the mental health industry, most notably in Manufacturing Depression: The Secret History of a Modern Disease. The DSM-5, the APA’s latest, largest overhaul since the 1980 debut of the DSM-III, is in his crosshairs (both Greenberg’s The Book of Woe and the new DSM-5 are being released this month).
The DSM began as a literary 132 pages steeped in Freudian psychoanalysis that allowed for contradiction and imprecision. The DSM-5 is a 992-page behemoth that eradicates nuance, requiring that x number of symptoms be met to qualify for diagnosis y. Greenberg asserts that “the DSM is at its best a clumsy and imperfect field guide to our foibles and at its worst a compendium of expert opinions masquerading as scientific truths, a book whose credibility surpasses its integrity, whose usefulness is primarily commercial, and whose most ardent defenders are reduced to arguing that it should be taken less seriously even as all of us—clinicians, researchers, and copyright holders alike—cash in on the fact that it is not,” he writes.
“It would be better if it didn’t have the weight, if it truly was just a way that clinicians communicated with each other ... like a book of shorthand,” he says.
Greenberg spent two years embedded in the contentious collaborative effort to maintain the book’s authority and relevance. He bears witness to a civil war waged in conference rooms across the country, where revisionists battling over which disorders to rehabilitate, which to chuck, how much emphasis to place on dimensional measures of mental illness and even what to call it—DSM-V or -5. (“‘If I could be permitted just one ad hominem response, do you treat post-traumatic stress disorder or just cause it?’” snipes one presenter at “The Future of Psychiatric Nosology” conference in Waikiki.) Biggest and best of all are the collaborations and clashes of the DSM’s varied helmsmen: old titans Robert Spitzer and Allen Frances; and current leaders Darrel Regier and Michael First. Greenberg tells their stories with critical wit, and compassion when applicable. “The problem isn’t that you have these bad guys running the DSM-5, but the DSM itself is a doomed enterprise,” he says.
What dooms the DSM-5 are a tendency to push the boundaries of psychiatry further into everyday life, creating new disorders and therapies; to disenfranchise groups of people who have built identities around diagnoses that will no longer exist (e.g., Asperger’s will be folded into Autism Spectrum Disorders); and to further the trend toward the commodification of suffering. But with their challenges laid bare, Greenberg believes that it’s the APA who will ultimately pay. “I think it’s going to suffer. I don’t think they can maintain this franchise. The world is a different place; we’re much more suspicious of institutions,” says Greenberg.
Perhaps rightfully so. In spite of a pledge to shed light on their methodology and findings, Greenberg says the APA proper stymies his requests for official information and interviews and asks its task force and work group members to refrain from talking with reporters about the DSM-5's "criteria or text." The APA responds that, "In developing DSM-5, the APA embarked on a very thorough process designed to get a great deal of feedback and to provide unprecedented transparency into the process. This has involved bringing in a number of professional mental health disciplines such as psychologists, physicians, and social workers to be included in the development of this publication. In addition, along the way, we provided key stakeholders, such as condition-specific patient groups, with regular briefings and updates. In putting together this important and landmark publication, we have continuously worked with various members of the media to share greater insights into issues of mental health conditions in general, and in particular, in the thinking behind the specific changes made to the DSM. This process included making a number of our experts available for interviews.” Nonetheless, Greenberg says that the APA's director of communications told him via email that no one will talk to him because of a "deeply negative and biased" Wired article he wrote. “[The APA’s] response to the people who criticize them and their ability to defend their own work has been so terrible, it’s embarrassing how bad they are,” he says. “When I say I feel bad for them, I actually mean that.”
Megan Labrise is a freelance writer and columnist based in New York. Follow her on Twitter @mlabrise.